Breyanzi denied for missing prior authorization by Cigna?

Cigna's specific coverage criteria for breyanzi are defined in its own published medical/coverage policy and the FDA-approved prescribing label. A successful appeal documents that your medical records satisfy each criterion those sources list — confirmed diagnosis, any required prior treatments (with dates and outcomes), and clinical severity. If the exact criteria weren't included with your denial, request them in writing; your appeal then maps each requirement to the matching fact in your chart.

## Why Cigna Denied Breyanzi: Prior Authorization Required

A prior authorization (PA) denial for Breyanzi (lisocabtagene maraleucel) means either that authorization was not obtained before treatment began, or that an authorization request was submitted and denied. These are two distinct situations that call for different appeal strategies.

If Breyanzi was administered in an emergency or urgent situation without time to obtain prior authorization, federal and state law provide specific protections. If a PA request was submitted and denied, your appeal is a clinical documentation exercise — demonstrating that your case meets every criterion in Cigna's coverage policy for Breyanzi.

## Why This Denial Is Appealable

Prior authorization requirements for CAR-T therapies are subject to utilization management rules under ERISA and the ACA. Cigna must apply its criteria consistently and in good faith. If your case meets the FDA-approved indication and all documented coverage criteria, a PA denial is routinely overturned on appeal. Retroactive PA denials for urgent CAR-T treatment are also frequently reversed where the clinical urgency is well-documented.

## Federal Appeal Framework

• Internal appeal (ERISA §503 / ACA §2719): File within 180 days of the denial. Pre-service PA denials must be decided within 30 days (standard) or 72 hours (urgent/expedited). Post-service denials within 60 days.
• Expedited appeal: If disease progression makes waiting dangerous, request expedited review explicitly — in writing and by phone — at the time you file.
• External review (ACA §2719): Available after exhausting internal appeals, generally within 4 months. An IRO evaluates whether Cigna's PA criteria were clinically appropriate and correctly applied. Binding on Cigna.
• Retroactive PA exception: If treatment was provided without PA due to clinical urgency or administrative error, cite the applicable state or federal retroactive authorization rules in your appeal letter.

## Documentation to Gather

• Original PA request and denial — dates, criteria cited by Cigna, and any deficiencies Cigna identified in the original submission
• Oncologist's PA support letter — must address every criterion in Cigna's Breyanzi/CAR-T coverage policy; state the diagnosis, disease status, prior-therapy history, performance status, and that all eligibility parameters in the FDA label are met
• Complete treatment history with dates, regimens, responses, and reasons for discontinuation of each prior line of therapy
• Pathology and staging records confirming diagnosis
• Cigna's current Breyanzi / CAR-T medical coverage policy — obtain the version in effect at time of denial; your appeal must address each listed PA criterion by name
• Treating center's credentials (FACT accreditation or equivalent) if required by the policy

## Criteria-Mapping Structure

For each PA criterion in Cigna's policy, document your answer:

| PA Criterion | Your Evidence | |---|---| | Diagnosis / indication | [Pathology report, date, and histologic finding] | | Relapsed/refractory status | [Number and type of prior lines; dates and outcomes] | | Performance status | [Most recent documented performance status] | | Organ function / eligibility parameters | ["Within parameters in FDA label" + lab date] | | Prescribing physician / center qualifications | [Oncologist credentials; FACT accreditation status] | | Urgency / retroactive PA exception (if applicable) | [Clinical notes documenting urgency at time of treatment] |

A complete, criterion-by-criterion response to the PA policy — with the oncologist's letter as the anchor document — is the most effective way to overturn a prior-authorization denial for Breyanzi.